Coping Well: Implementing the Principles of Stress Resilience

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Coping WellImplementing the Principles of
Stress Resilience

• N. Lee Smith, MD
• Adjunct Associate Professor of Medicine
• University of Utah
• Director, Stress Medicine
• Lifetree Clinical Research and Pain Clinic
• Salt Lake City, Utah

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Our purposes today-To identify

• Four core principles of stress resilience
• And what these have do do with mental and
  physical well-being (health)
• Some specific techniques for applying these
  principles

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What does mental stress have to do with medical
illness?
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INTERHEART Study Significance of Coronary Risk
Factors(15123 MI Cases 14820 controls 52
countries)
Attributable Risk
Smoking Depression Obesity Hypertension
Yusef S also Rosengren A. Lancet
2004364937-52 and 364953-62
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Outcome Effects of Treating MI Depression with
Sertraline(SADHART Trial n 369)
Mortality 2nd MI Angina CHF
Stroke
Percent reduction from placebo
Glassman AH, (SADHART) JAMA 2002288701-709
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Many Very Common Medical Problems Involve Central
Nervous System Hypersensitivity

• Irritable bowel syndrome
• Atypical chest pain
• Migraine and Tension Headaches
• Fibromyalgia Myofascial Pain Syndromes
• Anxiety and depression disorders

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Inhibitory track serotonin, norepinephrine,
dopamine
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Interventions improving chronic pain and
hypersensitivity usually require improvements
in the central function of

• Serotonin
• Norepinephrine
• Dopamine
• Endorphins
• GABA
• Deep sleep
• Reduced sympathetic tone

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What are the effects of cognitive-behavioral
interventions on these protective mechanisms?

• Sense of internal control ? ?Serotonin
• Love, cooperation ? ?Dopamine,?Endorphins
• Exercise, pos. excitement ? ? NE and DA Turned
  on-purpose ? ? Endorphins
• Deep Relaxation, ? ? Sleep, ?Serotonin
  mindfulness ? ? sympathetic
  tone meditation ? ? GABA (?)

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Coping Styles and Health 45 year Harvard Study
(Vaillant, et al)

• Coping Styles
• Denial
• Blaming and victimizing
• denying personal responsibility
• Repression, intellectualizing
• Mature, adaptive
• Internal control, connectedness, humor

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Coping Styles and Health Outcomes

• Styles 20 years later tended to be the same
  (with no intervention)
• Middle age (53) chronic illness or death
• Mature adaptive style 3
• The others combined 37
• Additional analysis
• optimism (hope) and altruism (meaning) were
  important for outcome

Vaillant G, et al also Seligman M and Peterson C
Learned Optimism 1990s
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Connectedness and Health

• Roseto, PA study
• 1/6 the national average of MIs and CV death
• Average exercise, smoking, obesity, hypertension
• Multifactorial analysis The keys
• Strong sense of community unconditional support
  Social and family ties Elderly honored
• When these deteriorated MI rates average
  Stewart Wolf, Temple Univ.
• (Compare 10000 Israeli men with CAD risk)

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Stress Hardiness The Three Cs

• Control
• Internal source of power to choose responses
• Refusal to be a victim
• Challenge
• Sees change as opportunity
• Enjoys growth
• Tightly linked to hope
• Commitment
• Curiosity and deep involvement
• Finding meaning and purpose

Suzanne Kobasa and Salvatore Maddi
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Four Principles of Stress Resilience Clearly
Related toImproved Health Outcomes

• An internal locus of control
• A sense of connectedness
• A sense of purpose and meaning
• Hope

Karren K, Smith NL, Hafen B, Frandsen K
Mind-Body Health (3rd edition) 2005 (San
Francisco, Benjamin Cummmings Publ)
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Dealing with Times of Chaos

• What gives a sense of control?
• Hope
• Loving support

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A Sense of Connectedness

• To ones deepest self
• To other people
• To the larger sources of ones power

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Is the way Im handling this situation

• Connecting us more deeply?
• or
• Disconnecting us?

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Does stress reduction work?

• If so, what are the keys to success?

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Stress and Heart Disease

• What are the
• cardiotoxic components of
• Type A behavior?

• Cynicism
• Hostility and anger
• ? Relationship problems

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Anger/Hostility and Carotid DiseaseMiddle aged
women- over 3 years
Percent progression on IMT
Lowest Highest Trait Anger Quartiles
Raikkonen K Psychosom Med 200466903-908
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Stress Reduction ReducesCarotid Atherosclerosis

• A meditation-based stress reduction program
  reduced carotid intimal thickening
• compared with health education
• in hypertensive African Americans
• carotid intimal thickening predictive of
  coronary disease
• The meditation group decrease in carotid
  intima-media thickness of -0.098 mm
• Control group increased of 0.054 mm
  Castillo-Richmond A. Stroke 200031(3)568-73

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Comparing Stress Reductionand Exercise in CAD
Patients
30
25
20
Coronary Events ()
15
10
5
0
Usual Care
Exercise
Stress
Reduction
Intervention
Blumenthal JA, et al Arch Int Med
19971572213-2223
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Stress Resilience can be learned

• It takes practicing experientially
• to do so

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Creating Stress Resilience

• Is stress good or bad?
• What makes the difference?
• An important key
• How much sense of control do you feel in dealing
  with it?

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Animal StudiesCancer Cell Rejection
Percent immune rejection of the cancer cells
-Martin Seligman, U. of Penn
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The Paradox of Control

• The more you try to take control of the world out
  there, the more out of control it
  seems
• The more you let go trying to control the
  external world (and stop blaming),
• and instead, respond in a way that you would
  deeply admire as wise,
• the more personal control you feel

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HindusYou have given your power (spirit) away.
Call your power back
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How to Create a Sense of Personal Control and Hope

• Conscious awareness I can respond as I
  choose.
• Relaxation skills To let go and get
  focused
• Clarify deep values How do I want to
  be?
• Visualizing (experiencing) responding the new way

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Creating Hope

• Visualizing (experiencing) ones self handling
  the situation well,
• in accord with wisdom and deepest values

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A Sense of Personal Controlhas much to do with
identifying ones deepest, wise values, then
creating ways to respond through them
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Creating ConnectednessWe have been highly
conditioned to see (and respond to) the world
through eyes of fear and judging

• Suppose instead, we saw through eyes of love

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lift each other
safe, acceptance
honest, authentic
kind
caring
A truly great relationship
honors needs
create hope
humor
win-win
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ExampleOverwhelmedHave too much to do
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A Philosophical CheckupDiscovering the core,
wise mind

• What is life really about, anyway?
• Productivity in numbers generated?
• Proving oneself worthy, or right?
• or
• Learning to love?
• Becoming wise and resilient?
• Making a difference?
• Joy?

Spiritual well-being
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A Philosophical CheckupDiscovering the core,
wise mind

• Why did I get into my work in the first place?
• external rewards? (income, status)
• or intrinsic meaning?
• What is the real purpose of my work?

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Journaling for Meaning

• Review your day backwards, asking
• What surprised me today?
• What moved or touched me today?
• What inspired me today?
• Look for the stories.
• After some time, the gap to seeing the answers
  will narrow, until they are seen as they happen

Remen RN. Int Med News 1/15/02, p.5
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What is Health? (from World Health Organization)

• Total well-being
• Physical
• Mental
• Social
• Spiritual

control (personal) connectedness meaning hope
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Summary(1)

• Depression, anxiety
  and associated
  traits of cynicism, hostility and anger are
  highly associated with cardiovascular disease and
  with many very common pain problems
• Several mechanisms of this are known
• Effectively teaching stress resilience (and
  treating dpression/anxiety) improves health
  outcomes

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Summary(2)
To be medically effective, stress resilience
training

• needs to be experiential
• needs to be directed at four core (spiritual)
  principles
• An internal locus of control (remember the
  paradox)
• Enhancing connectedness (oneness)
• Finding purpose and meaning (in all experience)
• Creating hope